Does pneumatic dilation still have a role in the treatment of achalasia? Choose pneumatic dilation

This is half of a two-part debate — read the opposing argument. The opinions expressed here are that of the author and do not represent the position of AGA.

The best treatments for achalasia disrupt the lower esophageal sphincter (LES) improving symptoms and esophageal emptying while preventing the progression to megaesophagus. The oldest of these treatments is brusque esophageal dilation, first performed in a patient with a dilated esophagus with a whale bone by Sir Thomas Willis in 1674. Over the last 75 years, these dilators have evolved from metal expanding arms to rubber latex balloons to the current Microvasive Rigiflex pneumatic balloon system (Boston Scientific, Boston, MA). These balloons are a polyethylene polymer, mounted on a flexible catheter usually passed over a guide-wire, 10 cm long and comes in three diameters (30, 35 and 40 mm). The original procedure seems grotesque but even as recently as 35 years ago, I recall doing this procedure with a Browne-McHardy bag with the patient in the sitting position and no anesthesia, as the idea was narcotics might relax the LES and prevent a good tear. It’s a wonder the patients ever came back, except for the fact that Heller myotomy through a thoracotomy incision was an even more morbid procedure. Fortunately, we now do pneumatic dilation as an outpatient procedure with conscious or propofol sedation and it adds less than five minutes to a standard upper endoscopy. So why is pneumatic dilation a seemingly “dying art” and will I be the last dinosaur to be performing this procedure? Said another way, where have all the true esophagologists gone – maybe they are all Barrett’s specialists now? Let me try to convince you that “old is still good” and “everything that glitters is not gold.”

It is easy: Done as an outpatient procedure, patients routinely return to work or play the next day. As I recently described in detail,1 the procedure is added to an upper endoscopy to screen for possible pseudoachalasia. All use a graduated system beginning first with the 30 mm balloon and progressing if necessary to the 35 mm and 40 mm balloons in separate sessions over two to four week intervals. Sometimes for young healthy men, the 35 mm balloon can be used initially as their LES is more difficult to tear. Also, I always start with a 35 mm balloon after Heller myotomy as the LES scarring makes pneumatic dilation for all balloon sizes less successful. The key to successful pneumatic dilation is accurate placement of the balloon which I prefer to do by fluoroscopy but can be done endoscopically. The balloon is located so the waist caused by the non-relaxing LES impinges on the middle portion of the balloon near the double opaque markers. The balloon is slowly distended until the waist is flattened. This usually requires 7 to 15 psi of air, which I hold for one minute while monitoring balloon position fluoroscopically. Others keep the balloon distended for 15 to 120 seconds and some do a repeat dilation before removal. The patient recovers for about one hour and I perform a barium esophagram before discharge to exclude a perforation. Patients can then travel home, I rest better, but they have my cell number if a later problem (rare) arises.

It works: If patients are selected well, the results are excellent and can be long term. The best candidates are older patients (more than 40 to 50 years) and women as it seems the pneumatic balloon gives a better stretch/tear here. Across multiple reports from the U.S. and Europe, a single series of dilations with symptom relief will consistently on average last for five to seven years and can be repeated as necessary.2 Usually, the 30 mm balloon gives relief in about 70 percent of patients, the 35 mm balloon adds another 10 to 15 percent and the 40 mm balloon allows an overall 90 percent success rate.2 For all comers, the randomized European Achalasia Trial found pneumatic dilation repeated up to two times equally effective to laparoscopic Heller myotomy at two (85 percent vs 90 percent, respectively) and five years (82 percent vs 84 percent, respectively).3,4 In the recent peroral endoscopic myotomy (POEM) randomized trial reported at DDW® 2017, POEM beat pneumatic dilation (95 percent vs 54 percent, respectively) at two years, but repeat pneumatic dilation as traditionally done was not allowed — a serious oversight or bias towards surgery. In my personal experience, I have had single pneumatic dilations relieve symptoms for up to 15 years in several women and up to 22 years in a young man.

On average, a single session of pneumatic dilation gives relief for five to seven years and can be repeated as necessary.

Low risk: The misunderstood and often misquoted perforation rate for pneumatic dilation in skilled hands should be less than 2 percent.2 Today, many of these perforations can be treated with esophageal stents and chest surgery is infrequent. In fact, the surgeons may perforate the esophagus more frequently in their operations (2 to 7 percent) then we do.5 Importantly, acid reflux disease requiring proton pump inhibitors (PPIs) is infrequent, usually less than 20 percent and much less than after traditional Heller-Dor or POEM operations (30 percent to 60 percent).2

Cost effective: Finally and it should make sense, pneumatic dilation is more cost-effective over a 10-year window than surgical procedures.2 At the University of South Florida, the usual cost of pneumatic dilation is $1,500, compared to 10 times that amount for lap Heller or POEM. If the operation lasts greater than 10 years with no complications, then surgery becomes favorable, but the data is limited and we have none for POEM.2

So, in the real world, what should we do in Achalasia Centers of Excellence? I strongly believe we should have all modalities for treating achalasia available and allow the patient to help with the final treatment decision after a balanced discussion about risks and benefits. Yes, young patients, men and type 3 achalasia are better treated with surgical myotomy, while older patients and women may do very well with pneumatic dilation. Furthermore, even in the surgical patients, you still will need pneumatic dilation for your failures or even to “touch up” your successes long term. Remember, we can’t cure achalasia.

Key takeaways

Pneumatic dilation is easy, adding five minutes to a standard endoscopy with total recovery in less than 24 hours.

On average, a single session of pneumatic dilation gives relief for five to seven years and can be repeated as necessary.

Current randomized trial found pneumatic dilation as successful as Heller myotomy over five years.

Dr. Richter is a Professor of Medicine, the Hugh F. Culverhouse Chair for Esophageal Disorders, Division Director for Digestive Diseases & Nutrition, and Director of the Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders at the University of South Florida Morsani College of Medicine in Tampa, FL.

One comment

Good review of the options –
I find pneumatic dilation equivalent to surgery in terms of effectiveness (but occ with a second dilation) – with some risk but also benefit of rapid and easy treatment. So I offer it as an equivalent treatment – and offer as an alternative – about 2/3 of my patients chose a surgical option. If they fail pneumatic, then surgery is a good option as well.
I estimate half of the dilations are in patient who have failed surgical rx (and have incompletely reduced LES pressures) – and then there is a higher change of limited or only transient response.

I also find good long term response – but I usually use the 35 mm pneumatic dilation – unless pt is slight or the EGJ seems very tight.